Surgical retractor

ABSTRACT

Apparatus and method for surgery is disclosed which includes a retractor having a substantially planar base defining an opening for overlying an operative site on a patient, and at least one retractor blade slidably mounted to the base. The base is positioned on the patient such that the opening therein overlies the operative site. The operative site is percutaneously accessed, and obstructing tissue is retracted by engaging the tissue with the retractor blade. A surgical instrument is provided which is engageable with the base and operable at the operative site through the opening in the base. A surgical procedure is carried out through the opening in the base with the surgical instrument.

CROSS REFERENCE TO RELATED APPLICATION

[0001] This application claims priority to U.S. Provisional ApplicationSerial No. 60/016,325 filed Apr. 26, 1996.

BACKGROUND

[0002] 1. Technical Field

[0003] The subject disclosure relates to minimally invasive surgicalprocedures and apparatus, and more particularly to an instrument andmethod for performing surgery associated with the thoracic cavity.

[0004] 2. Background of Related Art

[0005] The diagnosis and treatment of coronary disease and relatedconditions typically requires access to the heart, blood vessels andassociated tissue. Such procedures include cardiopulmonary bypass, valverepair and replacement, and treatment of aneurysms. Access to thepatient's thoracic cavity may be achieved by a large longitudinalincision in the chest This procedure, referred to as a mediansternotomy, requires a saw or other cutting instrument to cut thesternum and allow two opposing halves of the rib cages to be spreadapart. U.S. Pat. No. 5,025,779 to Bugge discloses a retractor which isdesigned to grip opposite sternum halves and spread the thoracic cavityapart. The large opening which is created by this technique enables thesurgeon to directly visualize the surgical site and perform procedureson the affected organs. However, such procedures that involve largeincisions and substantial displacement of the rib cage are oftentraumatic to the patient with significant attendant risks. The recoveryperiod may be extended and is often painful. Furthermore, patients forwhom coronary surgery is indicated may need to forego such surgery dueto the risks involved with gaining access to the heart.

[0006] U.S. Pat. No. 5,503,617 to Jako discloses a retractor configuredto be held by the surgeon for use in vascular or cardiac surgery toretract and hold ribs apart to allow access to the heart or a lungthrough an operating window. The retractor includes a rigid frame and atranslation frame slidably connected to the rigid fame. Lower and upperblades are rotatably mounted to the rigid frame and the translationframe respectively.

[0007] Once access to the thoracic cavity has been achieved, surgery onthe heart may be performed. Such procedures typically require that theheart beat be arrested while maintaining circulation throughout the restof the body. Cardioplegic fluid, such as potassium chloride (KCl) isdelivered to the blood vessels of the heart to paralyze the myocardium.As disclosed in WO 95/15715 to Sterman et al. for example, cardioplegicfluid is infused into the myocardium through the coronary arteries by acatheter inserted into the ascending aorta. Alternatively, cardioplegicfluid is infused through the coronary veins in a retrograde manner by acatheter positioned in the interior jugular vein accessed at thepatient's neck. Such procedures require the introduction of multiplecatheters into the blood vessels adjacent the heart, which is acomplicated procedure requiring that the desired vessels be properlylocated and accessed. The progression of the guide wires and cathetersmust be closely monitored to determine proper placement. Furthermore,the introduction of catheters forms punctures in the blood vessels thatmust be subsequently closed, and there is an increased risk of trauma tothe interior walls of the vessels in which the catheters must pass.

[0008] Therefore, a need exists for an apparatus and procedure whichprovides access to the thoracic cavity without causing extensive traumato the patient. A procedure is needed to at least locally stabilize apredetermined area of the heart surface that is relatively simple toperform and incorporates instruments that are simple and reliable.Furthermore, an apparatus and procedure is needed which provides astable framework for supporting additional instruments which may be usedduring these procedures.

SUMMARY

[0009] The present disclosure is directed to instruments for and methodsof surgery. A retractor is provided which has a substantially planarbase defining an opening for overlying an operative site on a patient,and at least one retractor blade slidably mounted to the base.

[0010] The base is positioned on the patient such that the openingtherein overlies the operative site, and the operative site ispercutaneously accessed through the opening. Obstructing tissue isretracted with one or more retractor blades to create an opening toprovide access for the surgical procedure. A surgical instrument isprovided which is engageable with the base and operable at the operativesite. A surgical procedure is carried out through the opening in thebase with the surgical instrument.

[0011] In a preferred embodiment, the retractor blade includes a ratchetassembly, and the method includes fixing the position of the retractorblade with respect to the base with the ratchet assembly.

[0012] The retractor blade may also include an integral blowing,irrigation or suction assembly operably positioned adjacent the blade toremove blood, fluid, etc. In another embodiment, a light assembly may beincorporated to illuminate designated portions of the surgical field.

[0013] A heart manipulator is disclosed for use in conjunction with theretractor and is releasably mountable on the base. The heart manipulatorassists in atraumatically holding and positioning the heart tofacilitate access thereto. In a preferred embodiment the heartmanipulator includes a loop shaped frame which supports a mesh cradle.

[0014] A heart stabilizer instrument is also disclosed. This instrumentis preferably configured to be mounted to the base portion and has aheart contacting surface. The heart may be contacted with the heartcontacting surface to stabilize the position of a predetermined portionof the heart surface. A heart stabilizer instrument may be providedwhich is mounted to the base portion and movable with respect thereto.The predetermined portion of the heart surface is substantiallystabilized by applying pressure thereto. In a preferred embodiment, theheart stabilizer instrument includes structure configured to compressthe coronary artery, and the step of stabilizing a predetermined portionof the heart surface includes applying pressure to the coronary arterywith the heart stabilizer instrument. The position of the heartstabilizing device may be locked with respect to the base.

[0015] The base may be provided to the hospital and/or surgeon in a kitform including one or more retractors. The kit may also advantageouslyinclude a heart manipulator and/or heart stabilizing device.

[0016] The surgical method may further include providing an actuatorassociated with the retractor blade and configured to effect linearmovement of the retractor blade.

[0017] These and other features of the surgical retractor and method forheart surgery will become more readily apparent to those skilled in theart from the following detailed description of preferred embodiments ofthe subject disclosure.

BRIEF DESCRIPTION OF THE DRAWINGS

[0018] Various embodiments of the subject surgical apparatus aredescribed herein with reference to the drawings wherein:

[0019]FIG. 1 is a perspective view of a surgical retractor constructedin accordance with a first embodiment of the subject disclosure;

[0020]FIG. 2 is an enlarged perspective view with parts separated of aretractor blade assembly of the surgical retractor of FIG. 1;

[0021]FIG. 3 is an enlarged cross-sectional view of a portion of theretractor blade assembly, illustrating the mounting of the retractorblade assembly on the base;

[0022]FIG. 4 is an enlarged cross-sectional view taken along line 4-4 ofFIG. 1 of the retractor blade assembly mounted to the base;

[0023]FIG. 5 is an enlarged top view, illustrating the radially inwardmovement of the retractor blade with respect to the base;

[0024]FIG. 6 is an enlarged top view, illustrating the ratchet on theretractor blade in engagement with the pawl member associated with thebase;

[0025]FIG. 7 is an enlarged top view, illustrating the pawl memberassociated with the base moved out of engagement with the retractorblade assembly;

[0026]FIG. 8 is a perspective view of one embodiment of a heartmanipulator mounted to a base;

[0027]FIG. 9 is a perspective view of a heart manipulator mounted to thebase and constructed in accordance with another embodiment;

[0028]FIG. 10 is an enlarged perspective view of a heart stabilizerinstrument mounted to the base;

[0029]FIG. 11 is a top view in reduced scale of the base portionpositioned on the patient's chest;

[0030]FIG. 12 is a top view, illustrating retractor blade assembliesmounted to the base portion and retracting the patient's ribs;

[0031]FIG. 13 is a top view, illustrating a heart manipulator inposition adjacent the patient's heart;

[0032]FIG. 14 is an enlarged side view in cross-section, illustrating aheart manipulator mounted to the base and spaced from the heart;

[0033]FIG. 15 is an enlarged side view in cross-section, illustrating aheart manipulator in contact with the heart;

[0034]FIG. 16 is a top view, illustrating the heart stabilizerinstrument of FIG. 10 mounted to the base;

[0035]FIG. 17 is a perspective view of the heart stabilizer instrumentof FIG. 10 mounted to the base and spaced from the heart;

[0036]FIG. 18 is a perspective view of the heart stabilizer instrumentof FIG. 10 in contact with the heart;

[0037]FIG. 19 is a perspective view of a surgical retractor assembly andbase constructed in accordance with another embodiment of the subjectdisclosure;

[0038]FIG. 20 is an enlarged perspective view with parts separated ofthe retractor blade assembly;

[0039]FIG. 21 is an enlarged perspective view from below of theretraction knob, illustrating the pinion gearing disposed thereon;

[0040]FIG. 22 is an enlarged cross-sectional view of the retractor bladeassembly mounted to the base;

[0041]FIG. 23 is an enlarged cross-sectional view of the retractor bladeassembly in the process of being mounted to the base;

[0042]FIG. 24 is an enlarged top view illustrating the radially outwardtranslation of the retractor blade;

[0043]FIG. 25 is an enlarged top view of the pawl member associated withthe base in engagement with the retractor blade;

[0044]FIG. 26 is an enlarged top view, illustrating the pawl membermoved out of engagement with the retractor blade;

[0045]FIG. 27 is a perspective view of a heart manipulator constructedin accordance with yet another embodiment of the subject disclosure;

[0046]FIG. 28 is an enlarged cross-sectional view of the mountingassembly for the heart manipulator of FIG. 27;

[0047]FIG. 29 is a perspective view of a heart stabilizer instrumentconstructed in accordance with another embodiment of the subjectdisclosure;

[0048]FIG. 30 is an enlarged cross-sectional view of the mountingassembly of the heart stabilizer instrument of FIG. 29 in an unlockedposition;

[0049]FIG. 31 is an enlarged cross-sectional view of the mountingassembly of the heart stabilizer instrument of FIG. 29 in a lockedposition;

[0050]FIG. 32 is a cross-sectional view taken along line 32-32 of FIG.31 illustrating the mounting assembly;

[0051]FIG. 33 is a top view of the surgical retractor positioned on thepatient's chest, illustrating retractor blade assemblies, a heartmanipulator and a heart stabilizer instrument mounted to the base;

[0052]FIG. 34 is a perspective view of a surgical retractor constructedin accordance with another embodiment of the subject disclosure;

[0053]FIG. 35 is a perspective view with parts separated of a retractorblade assembly of the surgical retractor of FIG. 34;

[0054]FIG. 36 is an enlarged side cross-sectional view of the retractorblade assembly, illustrating the positioning adjacent a rib and themounting of the retractor blade assembly on the base;

[0055]FIG. 37 is an enlarged side cross-sectional view of the retractorblade assembly mounted to the base and in the process of retracting arib;

[0056]FIG. 38 is a perspective view, illustrating the pawl member andthe retractor blade in engagement;

[0057]FIG. 39 is an enlarged cross-sectional view taken along line 39-39of FIG. 37, illustrating the ratchet on the retractor blade inengagement with the pawl member; FIG. 40 is an enlarged cross-sectionalview, illustrating the pawl member associated with the base moved out ofengagement with the retractor blade;

[0058]FIG. 41 is a perspective view of another embodiment of a heartstabilizer instrument mounted to the base of FIG. 34;

[0059]FIG. 42 is a perspective view with parts separated of the heartstabilizer instrument of FIG. 41;

[0060]FIG. 42A is a perspective view of the toggle member, illustratingthe cable mounting configuration;

[0061]FIG. 42B is a perspective view from below of the heart stabilizerinstrument of FIG. 41;

[0062]FIG. 43 is a side cross-sectional view of the heart stabilizerinstrument of FIG. 41;

[0063]FIG. 44 is a side view in partial cross-section of the heartstabilizer instrument in an unlocked configuration;

[0064]FIG. 45 is an enlarged cross-sectional view of the togglemechanism in an unlocked configuration;

[0065]FIG. 46 is an enlarged cross-sectional view of a portion of thearticulating arm, illustrating the cable in a loose configurationcorresponding to the unlocked configuration of FIGS. 44-45;

[0066]FIG. 47 is an enlarged cross-sectional view of the togglemechanism in an locked configuration;

[0067]FIG. 48 is a reduced scale side view in partial cross-section ofthe heart stabilizer instrument in an locked configuration;

[0068]FIG. 49 is an enlarged cross-sectional view of a portion of thearticulating arm, illustrating the cable in a tightened configurationcorresponding to the locked configuration of FIGS. 47-48;

[0069]FIG. 50 is an perspective view of a heart stabilizer instrumentmounted to the base in accordance with another embodiment of the presentdisclosure;

[0070]FIG. 50A is an enlarged perspective view of the link members ofthe heart stabilizer instrument of FIG. 50;

[0071]FIG. 50B is an enlarged perspective view of the link members ofthe heart stabilizer instrument of FIG. 50;

[0072]FIG. 51 is a perspective view of a surgical retraction system inaccordance with another embodiment of the subject disclosureincorporating a variety of retractors, a heart manipulator and a heartstabilizer, all positioned on a base;

[0073]FIG. 52 is a top view of the base of FIG. 51 illustrating suturemounts positioned thereabout; FIG. 53 is an enlarged perspective view ofthe suture mounts of FIG. 52;

[0074]FIG. 54 is a perspective view of a surgical retractor inaccordance with the subject disclosure incorporating an integral blowingstructure;

[0075]FIG. 55 is a reverse perspective view of the surgical retractor ofFIG. 54;

[0076]FIG. 56 is an enlarged perspective view with parts separated ofthe surgical retractor of FIG. 54;

[0077]FIG. 57 is a perspective view of a surgical retractor inaccordance with the subject disclosure incorporating a light;

[0078]FIG. 58 is a reverse perspective view of the surgical retractor ofFIG. 57;

[0079]FIG. 58A is a top plan view in partial cross-section of a surgicalretractor mounted to the base of FIG. 52;

[0080]FIG. 58B is a top plan view in partial cross-section of thesurgical retractor in FIG. 58A pulled proximally relative to the base;

[0081]FIG. 58C is a top plan view in partial cross-section of thesurgical retractor in FIG. 58A released from engagement with the rack;

[0082]FIG. 59 is a perspective view of another embodiment of a heartstabilizer instrument in accordance with the subject disclosure;

[0083]FIG. 60 is an enlarged perspective view of a portion of the heartstabilizer instrument of FIG. 59, illustrating a positioning flangeformed thereon;

[0084]FIG. 61 is a perspective view with parts separated of the heartstabilizer instrument of FIG. 59;

[0085]FIG. 62 is a perspective view of the mounting flange member of theheart stabilizer instrument of FIG. 59;

[0086]FIG. 63 is a perspective view of the movable handle of the heartstabilizer instrument of FIG. 59;

[0087]FIG. 64 is a top plan view in partial cross-section of the heartstabilizer instrument of FIG. 59 with the movable handle in the unlockedunstressed position;

[0088]FIG. 65 is a cross-sectional view taken along line 65-65 of FIG.64, illustrating the relative position of the handle spring member;

[0089]FIG. 66 is a top plan view in partial cross-section of the heartstabilizer instrument of FIG. 59 with the movable handle in the lockedunstressed position;

[0090]FIG. 67 is a cross-sectional view taken along line 67-67 of FIG.66, illustrating the relative position of the handle spring member; FIG.68 is a top plan view in partial cross-section of the heart stabilizerinstrument of FIG. 59 with the movable handle in the locked and stressedposition;

[0091]FIG. 69 is a cross-sectional view taken along line 69-69 of FIG.68, illustrating the relative position of the handle spring member;

[0092]FIG. 70 is a perspective view of another embodiment of a heartmanipulator;

[0093]FIG. 71A and 71B are front and back perspective views of the ribelevator;

[0094]FIG. 72 is a perspective view of a kit assembly having a base,three retractors, a retraction knob, a heart manipulator and a heartstabilizer instrument; and

[0095]FIG. 73 is a perspective view of a kit assembly having a base, aretraction knob and three retractors.

DETAILED DESCRIPTION OF PREFERRED EMBODIMENTS

[0096] The preferred embodiments of the apparatus disclosed herein willbe discussed in terms of procedures and apparatus for heart surgery.However, the subject disclosure should not be limited to an apparatusfor use in conjunction with such heart surgery, but may find applicationin surgery wherein access to the surgical site is achieved through asmall incision and retraction of the surrounding tissues and/or bone isdesired.

[0097] Referring now in detail to the drawings in which like referencenumerals identify similar or identical elements, a first embodiment ofthe surgical retractor of the subject disclosure is illustrated in FIG.1, and is designated generally by reference numeral 10. Surgicalretractor 10 has base 12 and retractor blade assembly 14, includingmounting assembly 16 and retractor blade 18. As will be described below,base 12 in this embodiment is configured to be placed on the chest of apatient surrounding an incision. Retractor blade 18 includes hook 20configured for atraumatically engaging a rib. Strap 22 assists thesurgeon in drawing the retractor blade 18 radially outward andretracting a rib therewith. One-way ratchet assembly 23 on mountingassembly 16 retains retractor blade 18 in position. Base 12 is alsoconfigured to receive surgical instruments for mounting thereon, as willbe described below.

[0098] Base 12 preferably has a closed shape, such as an ovalconfiguration as shown, or a circle, polygon, or the like. Base 12 issized sufficiently large in order to enclose sufficient area to provideaccess to the operative site. The bottom portion of base 12 ispreferably configured to permit placement directly on the skin of thepatient with the base substantially flush with the patient's skin.Suture mounts 24a, 24b, 24c may be provided at several locations on thebase 12 to permit suture tie down of internal tissue structures such asthe pericardial sac. Outer periphery 26 of base 12 includes a series ofoutwardly extending teeth 27 formed thereon to provide additionalstability to the positioning of mounting assembly 16 and otherinstruments on base 12. Base 12 also includes a beveled inner surface 28with an inner lip 30, and top surface 32. Base 12 has a low profile whenplaced on the body. Base 12 is rigidly supported by pressure fromretractor blade assembly 14 on the ribs in three or four locations.Preferably, three retractor blade assemblies are disposed on base 12 at120° apart. Retractor blade assemblies may be disposed 90° apart.

[0099] Turning now to FIG. 2, mounting assembly 16 permits quick andstable mounting of the retractor blade assembly to base 12. Mountingassembly 16 includes mounting bracket 34, retainer block 36, andretainer spring 38. Gripping flange 40 on mounting bracket 34 isconfigured to engage inner lip 30 of base 12 (FIGS. 3 and 4). Sleeve 42forms an open-sided channel 44 for sliding reception of retractor blade18. Pawl member 46 is formed on mounting bracket 34 and has a series ofengaging teeth 48 which communicate with the open side of channel 44 forengaging retractor blade 18, as will be described below. Mountingbracket 34 defines a cavity 49 for mounting retainer block 36 therein.Cavity 49 is partially defined by outer retainer wall 50 with upperflange 51 and by inner wall 52 having aperture 53. Retainer block 36 isradially slidable within cavity 49 and is biased inward by retainerspring 38 such that engagement teeth 54 on retainer block 36 protrudethrough aperture 53, to engage teeth 27 provided on periphery 26 of base12. Retainer block 36 also includes handle 56 which permits the surgeonto move retainer block 36 towards retainer wall 50 against the bias ofretainer spring 38, in order to disengage teeth 54 from base 12.

[0100] Retractor blade 18 includes curved hook 20 on a distal endportion and slot 57 on a proximal end portion to receive flexible assiststrap 22 therethrough. A series of ratchet teeth 58 are provided on anedge of retractor blade 18 and engage teeth 48 of pawl member 46 whenretractor blade 18 is disposed in channel 44 of mounting bracket 34.

[0101] As illustrated in FIGS. 3-4, mounting assembly 16 is mounted tobase 12 in a simple, one-handed operation. FIG. 3 illustrates retainerblock 36 displaced towards retainer wall 50 against the normal bias ofretainer spring 38. Handle 56 of retainer block 36 facilitatesapproximation of retainer wall 50 with flange 51 of retainer wall 50.Mounting assembly 16 is lowered onto base 12 at an angle as shown suchthat gripping flange 40 engages inner lip 30 of base 12. Engagementteeth 54 are angled to permit camming over outer lip 60. FIG. 4illustrates mounting assembly 16 into position with respect to base 12,upon which retainer block 36 is released, which thereby returns inwardtowards base 12 under the normal bias of spring 38. Engagement teeth 54pass under outer lip 60 and engage teeth 27 on periphery 26 of base 12.

[0102] Turning to FIGS. 5-7, the progression of retractor blade 18 withrespect to mounting bracket 34 is illustrated. Ratchet assembly 23includes pawl 46 on mounting bracket 34 and teeth 58 on retractor blade18. Pawl 46 is normally biased towards retractor blade 18. Pawl teeth 48and retractor blade teeth 58 are each configured with a sloping portionand a straight portion. This permits retractor blade 18 to beprogressively displaced in a radially outward direction as indicated byarrow “O” in FIG. 5. As illustrated in FIG. 6, radially inwarddisplacement of retractor blade 18 is prevented by engagement of pawlteeth 48 and retractor blade teeth 58 under the normal bias of pawl 46.The arrangement of teeth, as shown in FIGS. 5-6 permits retraction of arib or other body structure and prevents slipping of or loss ofretraction force exerted by retractor 18. As illustrated in FIG. 7,retractor blade 18 is permitted to displace radially inward as indicatedby arrow “I” when pawl tab 62 is rotated clockwise causing it to moveaway from retractor blade 18 against its normal bias by actuation of tab62. Unrestricted movement of retractor blade 18 is permitted in bothradially inward and radially outward directions when tab 62 is moved tothe position of FIG. 7.

[0103]FIG. 8 illustrates a heart manipulator 64 for use in conjunctionwith surgical retractor 10 and for mounting on base 12. Heartmanipulator 64 includes loop shaped fame 66 that supports mesh surface68. Frame 66 and mesh surface 68 together form a heart contactingsurface for manipulating the heart therewith. Preferably, frame 66includes upright portion 70, generally horizontally extending portion 72and atraumatic curved end portion 74, which provide a surface forengaging and manipulating the heart. Frame 66 is supported by mountingbar 76 which is slidably received in support bracket 78 for heightadjustment. Set screw 80 secures mounting bar 76 with respect to supportbracket 78. Radial positioning of support bracket 78 and heartmanipulator 64 is achieved by slidable mounting of support bracket 78 onmounting assembly 82 which mounts to base 12 in a manner substantiallysimilar to that of mounting assembly 16 described above with respect toFIG. 3-4. Set screw 84 secures the radial position of heart manipulator64 with respect to mounting assembly 82. More particularly, supportbracket 78 has an elongated slot 79 formed therein which enables bracket78 to slide radially with respect to set screw 84 and mounting assembly82. As shown in FIG. 14, mounting assembly 82, like mounting assembly16, has a mounting bracket 83 which engages inner lip 30 of base 12,retainer block 81, and retainer spring 87. Handle 89 of retainer block81 enables the engagement and disengagement of mounting assembly 82 inthe same manner as mounting assembly 16 described above.

[0104] Turning to FIG. 9, a heart manipulator 90 is shown in accordancewith another preferred embodiment. Loop frame 66 and mounting assembly82 are substantially as described above with respect to heartmanipulator 64 in FIG. 8. Mounting bar 92 supports frame 66 and has asubstantially right angled bend 94 for slidable insertion in supportbracket 96. Radial position of heart manipulator 90 is achieved bysliding mounting bar 92 with respect to support bracket 96 and securedthereto by set screw 98. Although height adjustment of heart manipulator90 is not provided, access to the operative site is enhanced by theone-piece design of mounting bar 92.

[0105]FIG. 10 illustrates a heart stabilizer instrument 100, configuredto apply pressure to the coronary artery to reduce blood flow in theartery to allow anastomosis to the coronary artery and to reducemovement of the heart muscle between legs 104a, 104b in order to enablethe surgeon to perform cardiovascular surgery. Heart stabilizerinstrument 100 is mounted to base 12 by mounting assembly 82,substantially as described above. Heart stabilizer instrument 100includes frame 102 supporting legs 104a and 104b and transverse bars106a and 106b. Protrusion 108a is formed on transverse bar 106a, andprotrusion 108b is formed on transverse bar 106b. Protrusions 108a and108b have an atraumatic convex heart contacting surface and permit theexertion of localized pressure on the coronary artery when frame 102 iscompressed on the surface of the heart. Mounting bar 110 is slidablyreceived in support bracket 78 and secured with respect thereto by setscrew 80. Radial positioning of heart stabilizer instrument 100 withrespect to mounting assembly 82 is secured by a coupling means, such asset screw 84.

[0106] Turning now to FIG. 11, the operation of the surgical retractor10 will now be described. Conventional surgical techniques are used todetermine the location of the incision I accessing the chest cavity C.Base 12 is placed on the chest of the patient with the opening overlyingthe operative site. Incision I is made, exposing several ribs R₁, R₂,and R₃.

[0107] As illustrated in FIG. 12, retractor assemblies 14a, 14b, and 14care mounted to base 12 at various locations. Hook 20a is positionedaround a rib R₁. Assist strap 22a is used to provide a grip for thesurgeon to deflect and retract rib R₁ by pulling retractor blade 18radially outward. One way ratchet assembly 23a maintains retractor blade18 and consequently rib R₁ in position. Rib R₂ is retracted in asubstantially identical manner by hook 20b on retractor assembly 14b.Additional retractors are mounted and used to retract ribs until asufficiently large opening O in chest cavity C is defined in order toprovide access to the heart. Although three retractors are shown, it iscontemplated that a fewer number or a greater number of retractors couldbe utilized, and these retractors can be mounted anywhere along base 12in order to perform their function. For example, the sternum and thefourth and fifth ribs can be spread apart to create a window.Alternatively, the fourth and fifth ribs are cut from the sternum andspread to create a larger window. Alternatively, a fifth rib can be cut,and the sternum and the fourth and sixth ribs are spread.

[0108] Base 12 is at least partially held in position over the operativesite by tension created in retracting the ribs by retractor blades 18.Internal tissue structures may be tied down utilizing sutures passingthrough securement points 24a, 24b, 24c and 24d.

[0109] Turning now to FIG. 13, heart manipulator 64 is mounted to base12 in order to manipulate the position of heart H to facilitate thesurgery. With reference to FIG. 14, heart manipulator 64 is positionedin the chest cavity adjacent heart H. Frame 66 and mounting bar 76 canbe lowered and fixed by set screw 80 such that horizontal portion 72 andcurved end portion 74 are positioned slightly underneath heart H. Asillustrated in FIG. 15, heart manipulator 64 is displaced radiallyinward and against heart H by loosening set screw 84 and slidingmounting bar 92 in the direction of the arrow. When sufficient pressureis placed on the heart to substantially fix its position, heartmanipulator 64 is secured by the tightening of set screw 84.

[0110] With the heart manipulated to the desired position, FIG. 16illustrates the mounting of heart stabilizer instrument 100 to base 12.As illustrated in FIG. 17, heart stabilizer instrument 100 is positionedover heart H and more particularly, over coronary artery A. The radialpositioning of instrument 100 is accomplished by relative movement ofsupport bracket 78 with respect to mounting assembly 82.

[0111] As illustrated in FIG. 18, frame 102 and mounting bar 110 arelowered with respect to support bracket 78 such that frame 102 appliesdirect pressure on heart H. Protrusions 108a and 108b localize thispressure to substantially restrict the flow of blood from coronaryartery A and 104a and 104b reduce movement of the surface of the heartmuscle to facilitate the surgery. Heart movement is restricted by virtueof the leg pressure and the anti-slip texture of the legs 104a and 104b.The position of instrument 100 may be locked with respect to the base asset forth in detail below.

[0112] Turning now to FIGS. 19-33, another preferred embodiment of thesurgical retractor is disclosed at reference numeral 200. Instrument 200operates substantially as described above with regard to instrument 10,with the differences described hereinbelow. In particular, FIG. 19illustrates surgical retractor 200 having base 212 and retractor bladeassembly 214, which includes mounting bracket 216, retractor blade 218and retraction knob 220. The provision of retraction knob 220 enablesthe surgeon to achieve additional mechanical advantage in retracting arib.

[0113] Base 212 includes suture mounting portions 224a, 224b, 224c and224d for securing base 212 adjacent the surgical site. Base 212 furtherincludes beveled inner surface 228 with inner lip 230 and top surface232 in which a series of cylindrical recesses or openings 240 aredefined.

[0114] As illustrated in FIG. 20, mounting bracket 216 includes sleeve242 defining open-sided channel 244 for sliding reception of retractorblade 218. Pawl member 246 has a series of ratchet teeth 248 configuredto engage ratchet teeth 258 on retractor blade 218 when blade 218 isslidably inserted in channel 244.

[0115] Retraction knob 220 is rotatably positioned in aperture 236 inmounting bracket 216. With reference to FIG. 20 in conjunction with FIG.21, retraction knob 220 includes pinion gear 260 which cooperates withrack 262 provided on retractor blade 218. As will be described below,rotation of knob 220 provides additional mechanical advantage incooperation with one-way ratchet mechanism 23 to retract and/or advanceretractor blade 218.

[0116] As illustrated in FIGS. 22-23, retractor blade assembly 214 ismounted to base 212 in a simple, one-handed motion. Mounting bracket 216includes pin 264 on a bottom portion thereof dimensioned to be receivedin one of cylindrical recesses 240 in base portion 212. The length ofpin 264 is preferably substantially equivalent to the depth of recess240 to provide stability to mounting bracket 216. In addition, wedgeshaped inner portion 266 of mounting bracket 216 cooperates with beveledinner surface 228 of base 212 to facilitate positioning and to provideresistance against tilting of retractor blade 218. Mounting bracket 216is further secured in position by tab 270 which includes a flange 272which engages outer rim 274 of base 212. As illustrated in FIG. 23,removal and placement of mounting bracket 216 is accomplished bydeflecting flange 272 of tab 270 clear of outer rim 274. Tab 220includes rigid lever arm 276 which facilitates such deflection of tab270.

[0117] Turning to FIGS. 24-26, the interaction of retractor blade 218with respect to mounting bracket 216 is illustrated. Ratchet assembly223, which includes pawl 246 and sloping teeth 258 functionsubstantially as described above with respect to FIG. 5, and permitsretractor blade 218 to be progressively displaced radially outwardlywhile preventing radially inward displacement. Initially, assist straps22 (See, FIG. 19) are used by the surgeon to retract a rib. Retractingblade 218 is displaced radially outwardly as far as possible given thestrength of the surgeon. Subsequently, additional retraction force canbe applied to the rib by rotation of retraction knob 220. Pinion gear260 disposed on knob 220 engages rack 262 on retraction blade 218 andprovides additional leverage to the surgeon. As illustrated in FIG. 25,pawl 246 is normally biased against retraction blade 218 such thatratchet teeth 258 on blade 218 and ratchet teeth 248 on pawl 246 engageto prevent radially inward movement. It should be appreciated that knob220 is optionally removable so it can be used to retract each retractorblade 218.

[0118]FIG. 26 illustrates that pawl 246 may be rotated away fromretraction blade 218 by pivoting lever 262 to disengage teeth 258 and248. Unrestricted radial movement of retraction blade 218 is facilitatedthereby.

[0119] FIGS. 27-28 illustrated another embodiment of a heart manipulatorinstrument designated by reference numeral 300. Heart manipulator 300 isused to manipulate the position of the heart and operates substantiallyas described above with regard to heart manipulator 64, with thedifferences described below. In particular, heart manipulator 300includes frame member 302, formed in a modified “U” configuration havingan upright portion wherein the bars are parallel, including closelyspaced mounting portions 304a and 304b, more widely spaced meshsupporting portions 306a and 306b, and a curved horizontally extendingportion 308. Mesh supporting portions 306a and 306b and horizontallyextending portion 308 support a mesh surface 310 therebetween. Mountingportions 304a and 304b are snap fit within bores formed in supportbracket 320. It is contemplated that members 304a and 304b may beslidable with respect to bracket 320 and secured with set screws (notshown). Radial positioning of support bracket 320 is achieved byslidable mounting of support bracket 320 on mounting bracket 322. Setscrew 324 is used to secure the radial positioning of heart manipulator300. Elongated slot 330 allows movement of support bracket 320 withrespect to set screw-324 and mounting bracket 322.

[0120] Turning now to FIG. 28, mounting bracket 322 is configured tomount on base 212 substantially as described with respect to mountingbracket 216 in FIGS. 22-23. Pin 364 of bracket 322 is received in one ofopenings 240 in base 212. Tab 370 includes flange 372 which removablyengages outer rim 274 of base 212 and is disengaged by lever arm 376.Support bracket 320 is slidably mounted on mounting bracket 322 suchthat a portion of slot 330 is aligned over threaded bore 332. Set screw324 extends through slot 330 into bore 332 and includes collar 334 whichabuts a top surface of support bracket 320 to secure it against radialmovement.

[0121] FIGS. 29-32 illustrate a heart stabilizer instrument 350 inaccordance with another preferred embodiment of the subject disclosure.With reference to FIG. 29, heart stabilizer instrument 350 includesframe 102 and mounting bar 110. Frame 102 includes legs 104a and 104band transverse bars 106a and 106b having protrusions 108a and 108bsubstantially as described with respect to FIG. 10, above. Mounting bar110 is slidably received in a bore in support bracket 352 and securedwith respect thereto by set screw 354. Support bracket 352 is slidablewith respect to mounting bracket 356.

[0122] As illustrated in FIGS. 30-31, mounting bracket 356 is removablymounted on base portion 212 substantially as described with respect tomounting bracket 216 in FIGS. 22-23. Pin 358 is received in one ofcylindrical recesses or openings 240 in base 212. Tab 360 includesflange 362 for removably engaging outer rim 274 of bore 212. Flange 362is disengaged by actuation of lever arm 364. With reference to FIG. 32in conjunction with FIGS. 30-31, support bracket 352 includes a pair ofvertical walls 364a and 364b and a pair of horizontal walls 366a and366b which rest on a top surface of mounting bracket 356. A levermounting rod 368 extends upwardly from mounting bracket 356 betweenhorizontal walls 366a and 366b. A pair of hinge pins 370a and 370bextend from rod 368 and are received in a clevis portion 372 of leverarm 374. Horizontal walls 366a, 366b of support bracket 352 are disposedbetween mounting bracket 356 and clevis portion 372 of lever arm 374.

[0123] With continued reference to FIGS. 30-31, clevis portion 372 issubstantially circular or elliptical in lateral cross-section and iseccentrically mounted to hinge pins 370a and 370b. As illustrated inFIG. 30, when lever arm 374 is in a released position, clevis portion372 is spaced from horizontal walls 366a and 366b and unrestrictedradial movement of support bracket 352 is enabled thereby. Asillustrated in FIG. 31, pivoting of lever arm 374 causes clevis portion372 to apply a compressive force on horizontal walls 366a and 366b ontop of mounting bracket 356 to thereby fix the radial position ofsupport bracket 352 with respect to mounting bracket 356.

[0124] Turning to FIG. 33, operation of surgical retractor 200 inconjunction with heart manipulator and heart stabilizer instrumentproceeds substantially as described with respect to FIGS. 11-18. Asnoted above, mounting bracket 216a of retractor blade assembly 214 isplaced on base 212 by actuation of lever arm 276a (not shown). Heartmanipulator 200 and heart stabilizer instrument 350 are mounted to base212 in a substantially identical manner as described above. The surgicalprocedure is carried out substantially as described above. Ribs R₁, R₂and R₃ are retracted by the pulling of assist straps 22 and by therotation of retraction knob 220. The position of heart H is stabilizedby heart manipulator 300. Heart stabilizer instrument 350 is positionedand lowered onto heart H to apply pressure to the coronary artery andthereby substantially reduce movement (motion) of the heart within thelegs. The instrument 350 may be locked with respect to the base. At thistime, other surgical procedures, such as coronary bypass or valvesurgery may be performed.

[0125] Turning now to FIGS. 34-52, another embodiment of the surgicalretractor is disclosed at reference numeral 400. Instrument 400 operatessubstantially as described with regard to instrument 200, with thedifferences noted hereinbelow. In particular, FIG. 34 illustratessurgical retractor 400 having base 412 and retractor blade assembly 414,which includes mounting bracket 416, retractor blade 418, and retractionknob 420. The provision of retraction knob 420 enables the surgeon toachieve additional mechanical advantage in retracting a rib.

[0126] Base 412 includes suture mounting portions 424 for suture tiedown of internal tissue structures. Base 412 further includes beveledinner surface 428 with inner lip or rim 430 and top surface 432, whichforms an outer lip or rim 434. A channel or groove 436 is formed in topsurface 432. Outer periphery 438 of base 412 includes a series of teeth440 formed thereon.

[0127] As illustrated in FIG. 35, mounting bracket 416 includes housing442 and mounting plate 444 which are connected and allow retractor blade418 to slide within channel 446 defined in a lower surface of housing442.

[0128] Retractor blade 418 includes body portion 448 and rib engagingportion 450. Body portion 448 defines a T handle 452 configured to begrasped by the surgeon in order to slide retractor blade 418 withinchannel 446. Body portion 448 defines a rack gearing 454 and a series ofsloping ratchet teeth 456. Preferably, such gearing 454 and ratchetteeth 456 are respectively disposed along elongated channel 458 definedwithin body portion 448.

[0129] Ratchet teeth 456 are releasably engaged by pawl 460. Mountingplate 444 defines first channel 462 and second channel 464 for receivingpawl 460. Preferably, pawl 460 is a resilient member having a modifiedU-shaped configuration including crown portion 466, first leg 468defining cut-out portion 470, and second leg 472. Second leg 472 isfixedly retained within second channel 464 having an elbowconfiguration. The junction of second leg 472 and crown 466 acts as ahinge or pivot such that first leg 468 is slidable within first channel462. Pawl 460 is normally biased at this junction of second leg 472 andcrown 466 such that first leg 468 is partially disposed in first channel462. Crown 466 may be pressed by the user towards mounting plate 444against the normal bias to slide first leg 468 further along firstchannel 462. Retractor blade 418 is positioned adjacent mounting plate444, and pawl 460 is placed on top of blade 418 such that cut-outportion 470 of first leg 468 straddles a portion of blade 418 adjacentratchet teeth 456. (See, FIG. 38) As will be described below, pawl 460is normally biased such that first leg 468 is in engagement with one ofratchet teeth 456. Pawl 460 and ratchet teeth 456 together define aone-way.ratchet mechanism 474.

[0130] Rack gearing 454 is engaged by pinion gearing 476 formed onretraction knob 420, which is positioned in aperture 478 defined inhousing 442. As will be described below, rotation of retraction knob 420provides additional mechanical advantage when used in cooperation withratchet mechanism 474 to retract and/or advance retractor blade 418.

[0131] Rib engaging portion 450 is connected to body portion 448 with adovetail joint and secured thereto with pins 480a and 480b.Alternatively, retractor blade 418 may be constructed of a single part.Rib engaging portion 450 includes a horizontal portion 482, angularlydepending portion 484, and tip portion 486. Angularly depending portion484 forms an acute angle with horizontal portion 482 to securely engagethe rib. Strengthening rib or beading 488 is formed on the outside ofrib engaging portion 450 to provide additional strength and to resistbending.

[0132] Referring to FIG. 35 in conjunction with FIGS. 36-37, mountingplate 444 includes a gearing 490 on a forward portion thereof to engageperipheral gear teeth 440 on base 412 (See, FIG. 34).

[0133] As illustrated in FIG. 36, base 412 is placed at the operativesite on patient's chest. Rib engaging portion 450 is positioned adjacentrib R, such that angularly depending portion 484 and tip portion 486 atleast partially surround rib R. Housing 442 has a flat bottom portionand is placed on upper surface 432 of base 412.

[0134]FIG. 37 illustrates the simultaneous mounting of mounting bracket416 to base 412 and retraction of rib R towards base 412 as indicated bythe arrows. Retractor blade 418 is moved radially outward with respectto base 412 while rib engaging portion 450 engages rib R. Mounting plate444 is spaced from the bottom portion of housing 442 in order to permitmounting plate 444 to slide under outer rim 434 of base 412, and toallow teeth 490 engage teeth 440 on base 412. Mounting bracket 416 issecured on base 412 by the compression force created between ribengaging portion 450 against rib R and mounting plate 444 against outerrim 434 of base 412. Removal of retractor blade 418 from rib R occurs bysliding retractor blade 418 radially inward, thereby releasingcompression sufficiently to allow mounting plate 444 to be released fromouter rim 434.

[0135] One-way ratchet mechanism 474 enables retractor blade 418 to beincrementally moved in one direction, i.e. radially outwardly to retracta rib, while resisting movement in an opposite direction, i.e. radiallyinward. FIG. 38 illustrates pawl 460 normally biased such that first leg456 is in engagement with ratchet teeth 456. As shown in FIG. 39,sloping portions 490 of teeth 456 permit retractor blade 418 toincrementally move in a radially outward motion while transverse slopes492 of teeth 456 inhibit radially inward motion to hold retractor blade418 and the rib in position. As described above with respect toretractor 200, additional retraction force can be applied to the rib byrotation of retraction knob 420. Pinion gear 476 disposed on retractionknob 420 engages rack 454 on retraction blade 418 to provide additionalleverage to the surgeon. After retracting the rib to create sufficientaccess for the surgeon, rotation knob 420 may be removed from aperture478 in housing 442 (See, FIG. 35) and thereby provide greater visibilityand access for the surgeon.

[0136] Pawl 460 may be moved against its normal bias by depressing crown466 towards mounting plate 444, which causes first leg 468 to disengagefrom ratchet teeth 456 as shown in FIG. 40. Cut-out portion 470 asaligned such that blade 418 may slide therethrough, such thatunrestricted radial movement of retraction blade 418 is enabled.

[0137] FIGS. 41-49 illustrate a heart stabilizer instrument 500 inaccordance with another preferred embodiment of the subject disclosure.With reference to FIG. 41, heart stabilizer instrument 500 includesframe 502, articulating arm 504, and mounting assembly 506. Articulatingarm 504 is configured to allow frame 502 to be positioned at the preciselocation and orientation with respect to the heart of the patient.Mounting assembly 506 secures articulating arm 504 and frame 502 in afixed configuration, as will be described below.

[0138] Frame 502 is configured to contact the heart and applies pressureto the heart without touching the coronary artery. Frame 502 includes apair of legs 508a and 508b, each having teeth 510 for atraumaticallycontacting the heart. Frame 502 is mounted to frame mount 512 by pin514. The distal end of cable 516 is mounted to frame 502, and passesinto frame mount 512 at opening 513.

[0139] Articulation arm 504 consists of a plurality of link members518a, 518b, 518c, 518d, each of which has hemispherical convex distalportion 520, cylindrical body portion 522 including peripheral step 523,and concave proximal end 524. Bore 526 extends longitudinally througheach link 518 from convex distal portion 520 to concave proximal end524. Link members 518 are aligned such that convex distal portion 520 isreceived in concave proximal end 524 in a ball-and-socket typeconnection to permit a wide range of pivoting motion between adjoininglink members 518. Link members 518 are concatenated by cable 516 passingthrough each bore 526, and the distalmost link member 518a is fittedadjacent frame mount 512. Articulation arm 504 can be used to mount alight cable to illuminate the surgical site, a suction and/or irrigationdevice, a blowing device to disperse blood or any other instrument tofacilitate the surgery.

[0140] Mounting assembly 506 is mounted adjacent proximalmost linkmember 518d and includes mounting flange member 530, mounting base 532,toggle housing 534, and toggle 536. As shown in FIG. 42B, mounting base532 has a flat bottom surface 538 to rest on top surface 432 of base 412and a protrusion or peg 540 configured and dimensioned to be received inflange 436 of base 412. With continued reference to FIG. 42, mountingflange member 530 and toggle housing 534 are slidably mounted withrespect to mounting base 532 and are normally biased in a spaced-apartconfiguration from mounting base 532 by springs 542 and 544,respectively. Mounting flange member 530 has flange 546 for engaginginner rim 430 of base 412. Toggle housing 534 has flange 548 forengaging outer rim 434 of base 412.

[0141] Toggle 536 includes cylindrical mounting portion 550 and togglearm 552. Cylindrical mounting portion 550 is configured to be receivedwithin cylindrical recess 554 defined within toggle housing 534 and tobe pivotably movable therein. Cable 516 extends through link members 518and through mounting flange member 530, spring 542, mounting base 532,spring 544, and into cylindrical recess 554 of toggle housing 534. Thedistal end portion of cable 516 is pinned to toggle 536 by pin 556. Asillustrated in FIG. 42A, cylindrical mounting portion 550 defines alaterally offset pie-shaped or arc-section recess 558 to define an“over-center” type locking mechanism, as will be described below.

[0142] As illustrated in FIG. 43, heart stabilizer instrument 500 isconfigured such that cable 516 extends through instrument 500 from frame502 to toggle 536. Bore 526 in each link member 518 has a taperingdiameter which is larger adjacent convex distal portion 520 and isnarrower adjacent concave proximal portion 524. This configurationpermits relative articulation of link members 518 while cable 516extends therethrough.

[0143] FIGS. 44-46, illustrate heart stabilizer instrument 500 withcable 516 in a relaxed unstressed configuration. As illustrated in FIG.44, instrument 500 is placed on base 412 such that peg 540 is disposedin groove 436, and mounting flange member 530 and toggle housing 534 arespaced apart sufficiently to allow flanges 546 and 548 to clear innerrim 430 and outer rim 434, respectively.

[0144] As illustrated in FIG. 45, toggle 536 is disposed in togglehousing 534 in an unlocked configuration, such that toggle arm 552 andfixed arm 535 are spaced apart. Eccentrically mounted pin 556 isdisposed such that cable 516 is loose. FIG. 46 illustrates that cable516 loosely disposed in tapered bores 526 of link member 518 permitarticulation of adjoining link members 518.

[0145] FIGS. 47-49 illustrate instrument 500 with cable 516 in a taut,stressed configuration. As depicted in FIG. 47, toggle 536 is pivotedwith respect to toggle housing 534 such that toggle arm 552 isapproximated with fixed arm 535. Simultaneously, the distal end of cable516 connected to pin 556 moved into an “over-center” position, therebystressing cable 516 and locking surgical instrument 500 in position. Thesurgeon is permitted to perform other procedures without maintainingpressure on the heart.

[0146] Another embodiment of the heart stabilizer instrument isillustrated in FIG. 50 and disclosed at reference numeral 600.Instrument 600 is constructed and operates substantially as describedabove with regard to instrument 500, with the differences describedbelow. Heart stabilizer instrument 600 includes frame 502, articulatingarm 606 and mounting assembly 506. Articulating arm 606 permits frame502 to be placed at the appropriate height and angle with respect to theheart. Articulating arm 606 is composed of link members 608, and 610having a series of intermeshing teething to positively engage adjoininglink members together.

[0147] As illustrated in FIGS. 50A and SOB, link members 608 arepositioned adjacent link member 610. Link member 608 has generallycylindrical body portion 612. A pair of rows of concave gearing 614a and614b is disposed on one axial end 616 of link member 608. A second pairof rows of concave gearing 618a and 618b is disposed on the second axialend 620 of link member 608. Gearing 614a and 614b is disposed 90° out ofalignment with gearing 616a and 616b. Longitudinal bore 622 extendsthrough link member 608 from axial end 616 to axial end 620 between eachpair of gearing.

[0148] Link member 610 has body portion 624, to which first pair ofgearing 626a and 626b having a convex profile and second pair of convexgearing 628a and 628b are attached to opposite sides thereof. First pairof gearing 626a and 626b is disposed 90° out of alignment with secondpair of gearing 628a and 628b. A longitudinal bore (not shown) extendsthrough body portion 624 and between each pair of gearing 626a and 626band gearing 628a and 628b.

[0149] Link member 610 is placed adjacent link member 608. Cable 516extends through longitudinal bore 622 in link member 608 andlongitudinal bore (not shown) in link member 610. When toggle 552 ismoved to the “over center” position (See, FIG. 47), thereby tighteningcable 516, link members 608 and 610 are approximated such that convexgearing 626a, 626b or 628a, 628b of link member 610 engages concavegearing 614a, 614b and 618a, 618b of link member 608.

[0150]FIG. 51 illustrates another preferred embodiment of the surgicalretractor in accordance with the subject disclosure. This surgicalretractor, designated generally at 700, includes a base 702 and any oneor more of the instruments shown including: retractor blade assembly704; retractor blade assembly with suction/irrigation structure 706;retractor blade assembly with light 708; heart manipulator 710; andheart stabilizer instrument 712. These instruments are discussed ingreater detail hereinbelow.

[0151] Base 702 is configured in accordance with the other basesdiscussed above and provides a low profile mount for instrumentationused in the surgical procedure being performed. A plurality of suturemounts 714 are defined in an upper peripheral portion 716 of base 702and serve as attachment and anchor points for suture ends 718 from thesurgical field. Referring to FIGS. 52 and 53, suture mounts 714 includea tightly wound coil spring 720 positioned in a cavity 722 with thecoils oriented substantially transverse to the radians of the base 702.A triangular ramp 724 is formed on an inner radial surface of suturemount 714. A slot 726 is formed on an outer radial surface of suturemount 714 beyond coil spring 720 and in axial alignment with ramp 724.This ramp/slot configuration facilitates easy access to position sutureend 718 in coil spring 720.

[0152] The balance of base 702 is configured in substantially the samemanner as previously described bases and includes teeth 728, beveledinner peripheral surface 730 and inner lip 732.

[0153] Surgical retractor blade assembly with blowing structure 706 isshown in FIGS. 54-56. Structure 706 can also be used for suction or forirrigation to remove fluids from the surgical site. The retractor bladeassembly 704 is similar to the retractor blade assembly 414 discussed indetail above. Retractor blade assembly 704 includes mounting bracket734, retractor blade 736 and removable retraction knob 738.

[0154] As illustrated in FIG. 56, mounting bracket 734 includes housing740 and mounting plate 742 which together form a channel through whichretractor blade 736 is reciprocally slidable.

[0155] Retractor blade 736 includes body portion 744 and rib engagingportion 746. Body portion 744 defines a flanged gripping handle 748configured to be grasped by the surgeon in order to slide retractorblade 736 relative to mounting bracket 734. Body portion 744 furtherdefines longitudinally oriented rack gearing 750 and a series of slopingteeth 752. Rack gearing 750 and teeth 752 are disposed along elongatedcavity 754 defined in body portion 744.

[0156] Teeth 752 are releasably engaged by pawl 756 mounted in housing740. Operation of this pawl 756 is substantially the same as pawl 460described above in connection with retractor blade assembly 414.

[0157] Rib engaging portion 746 extends distally from body portion 744and includes an angularly depending portion including one or morestrengthening ribs 758 to provide additional strength.

[0158] Blowing structure 760 is integrally formed into the retractorblade assembly shown in FIGS. 54-56. This structure includes a tube 762which extends the length of the retractor blade assembly and exits thering engaging portion 764 to access the surgical site. A tube connector764 is positioned at a proximal end of tube 762 and connects to anappropriate source such as a vacuum or pressure source (not shown)depending on whether structure 760 is used for blowing, irrigation orsuction. Forming wire 766 is positioned adjacent tube 762 and isdeformable to configure tube 762 in a desired angular orientation.Alternatively, tube 762 may be remotely oriented or rotated from bodyportion 744 using known structure.

[0159]FIGS. 57 and 58 illustrate a retractor blade assembly with anintegral light shown generally at 708. The basic configuration andoperation of this assembly is identical to that described above with thedifference that a light 768 has been substituted for suction/irrigationstructure. A wide variety of lights can be accommodated. In theillustrated embodiment, a fiber optic bundle is disposed within alongitudinally extending sheath 770. A fiber optic coupler 772 ispositioned adjacent the proximal end of the assembly and can beconnected to an appropriate light source (not shown). It is alsoenvisioned that a wide variety of divergent and focusing lenses may beused to tailor the light as required by the surgeon.

[0160] The one-way ratchet mechanism used in these embodiments of theretractor blade assembly is shown in FIGS. 58A-C. This ratchet mechanismoperates in the same manner as the ratchet mechanism discussed abovewith respect to FIGS. 39-40. Note that as shown in FIG. 58B, theretractor blade 736 can be pulled in the direction of the arrow toretract the bone and tissue. However, to move the retractor blade 736 inthe opposite direction, i.e. the direction of the arrow of FIG. 58C,pawl 756 must be pressed in.

[0161] FIGS. 59-63 illustrate another embodiment of a heart stabilizerinstrument 800 in accordance with the subject disclosure. Heartstabilizer instrument 800 is substantially the same as heart stabilizerinstrument 500 discussed in detail above. The instrument includes frame802, articulating arm 804 and mounting assembly 806.

[0162] Frame 802 is configured in the same manner as frame 502 andincludes a pair of legs 808a and 808b, each having teeth 810 foratraumatically contacting the surface of the heart.

[0163] Frame 802 is connected to articulating arm 804 by connector 812.A positioning flange 814 is formed on connector 812 and facilitatespositioning of frame 802 on the heart surface either by manuallygrasping the flange 814 or by affixing a grasping instrument (not shown)to the flange 814 and positioning the frame in a desired location.

[0164] Mounting assembly 806 is mounted adjacent the articulating arm804 and includes mounting flange member 830, mounting base 832, togglehousing 834, and toggle 836. As shown in FIGS. 61-62, mounting base 832has a flat bottom surface 838 to rest on the top of base 702. Mountingflange member 830 and toggle housing 834 are slidably mounted withrespect to mounting base 832. Mounting flange member 830 has flange 846for engaging inner rim of base 702. Toggle housing 834 has flange 848for engaging outer rim of base 702.

[0165] Toggle 836 includes cylindrical mounting pins 850 and finger loop852. Cylindrical mounting pins 850 are configured to be received withinrecess 854 defined within toggle housing 834 and to be pivotably movabletherein. Cable 816 extends through articulating arm 804. The distal endportion of cable 816 is pinned to toggle 836 by clip 856. Biasing spring858 is positioned in toggle housing 834 and serves to normally biasmounting flange member 830 distally relative to toggle housing 834.

[0166] Handle spring member 860 is integrally formed on toggle 836 andis configured to operatively interact with protrusion 862 formed incavity 854 of toggle housing 834, as toggle 836 is moved into and out ofapproximation with toggle housing 834.

[0167] FIGS. 64-66, illustrate heart stabilizer instrument 800 withcable 816 in an unlocked, unstressed configuration. As illustrated inFIG. 64, instrument 800 is placed on base 702 with mounting flangemember 830 and toggle housing 834 spaced apart sufficiently to allowflanges 846 and 848 to clear inner rim 830 and outer rim 833,respectively.

[0168] Toggle 836 is disposed in toggle housing 834 in an unlockedconfiguration, such that finger loop 852 and finger loop 853 are spacedapart. Cable 816 is loose to permit manipulation of articulating arm804.

[0169]FIG. 65 illustrates the relative position of handle spring 860relative to protrusion 862 within toggle housing 834.

[0170] FIGS. 66-67 illustrate instrument 800 with cable 816 in a firsttaut, locked, unstressed configuration. As depicted in FIG. 66, toggle836 is pivoted with respect to toggle housing 834 such that finger loop852 is moved toward finger loop 853. The distal end of cable 816 isstressed to approximate mounting flange member 832 and mounting base 832locking surgical instrument 500 in position on base 702. FIG. 67 showsthe progression of toggle 836 relative to toggle housing 834 into thelocked, unstressed configuration. In this position, articulating arm 804can still be manipulated

[0171] The final, locked and stressed configuration is shown in FIGS.68-69. In this configuration, finger loops 852 and 853 have moved intoclose approximation simultaneously, further stressing cable 816 tomaintain a preset configuration desired by the surgeon, e.g. to lockarticulating arm 804 in place. Once locked into this locked-stressedconfiguration, the surgeon is permitted to perform other procedureswithout having to manually apply pressure on the heart via the heartstabilizer instrument.

[0172] Another preferred embodiment of the heart manipulator 900 inaccordance with the subject disclosure is shown in FIG. 70. The heartmanipulator includes a manipulator portion 902, an articulating arm 904and a mounting assembly 906. The structure and operation of mountingassembly 906 and articulating arm 904 are substantially the same as theheart stabilizer 800 discussed above.

[0173] The manipulator portion 902 includes a frame 908 supporting mesh910 and is preferably provided with a curved section adjacent a distalend thereof to assist in manipulation of the heart.

[0174]FIGS. 71A and 71B illustrate a rib elevator 980 which can bemounted to the aforedescribed bases to enable the patient's rib to belifted. Rib elevator 980 includes a set of tabs 982 which engage innerlip 732 for attachment to the base. Reinforcement ribs 984a, 984b formedon the rear surface 981, increase the rigidity of rib elevator 980 andalso provide a gripping surface fur the user to flex the rib elevator980 to facilitate attachment and removal from the base. Teeth 986function in the same manner as the teeth 728 of base 702, i.e. formounting one or more of retractor assemblies 704, 706, 708. As can beappreciate when rib elevator 980 is mounted to base 702, the mountedretractor assembly will be angled towards the rib so that a retractionforce will be applied to the rib partially in an upward direction. Thisis advantageous, for example, for access and severing of the IMA. Therib elevator 980 can subsequently be removed and a retractor assemblymounted directly to the base 702 in the manner described above.

[0175]FIGS. 71 and 72 illustrate two preferred kit configurations inaccordance with the subject disclosure. Kit 950 (FIG. 71) is formed toaccommodate a basic blade retractor assembly 704, a blade retractorassembly with suction irrigation 706, a blade retractor assembly withlight 708, a base 702, a retraction knob 738, a heart stabilizerinstrument 800 and/or a heart manipulator 900 therein. Cavities 952,954, 956, 958 and 960 are formed in cover 962 to accommodate theseelements. Cover 962 may be fixed to bottom 964 by adhesive, ultrasonicwelding, heating, etc.

[0176] Kit 970 is substantially similar to kit 950 except that the heartstabilizer instrument 800 and the heart manipulator 900 are excluded.Cover 972 includes cavities 952, 958 and 960 to accommodate retractors704, 706, 708, base 702 and retraction knob 738. Cover 972 and bottom974 may be joined in the same manner as disclosed for kit 950 above.

[0177] Rib elevator 980 can optionally be included in the kits.

[0178] It will be understood that various modifications may be made tothe embodiments shown herein. Therefore, the above description shouldnot be construed as limiting, but merely as exemplifications ofpreferred embodiments. Those skilled in the art will envision othermodifications within the scope and spirit of the claims appended hereto.

What is claimed is:
 1. A surgical retractor comprising: a) a monolithicbase defining an opening therethrough and an outer peripheral portionhaving engagement structure thereon; b) a retractor mounting assemblyincluding a mounting bracket and mounting bracket engagement structureslidable along the base and movable between a locked and unlockedposition, in the locked position, the base engagement structure abuttingthe mounting bracket engagement structure to lock the retractor mountingassembly in a predetermined radial position, the retractor mountingassembly further defining a cavity, and c) a retractor blade slidablypositioned in the cavity and configured to retract tissue through theopening in the base.
 2. A surgical apparatus as recited in claim 1 ,wherein the retractor mounting assembly includes a resilient flangeportion.
 3. A surgical apparatus as recited in claim 1 , wherein theretractor mounting assembly is normally biased in engagement with thebase.
 4. A surgical apparatus as recited in claim 1 , wherein theretractor mounting assembly has a textured surface formed thereon forengaging a complementary textured surface formed on the periphery of thebase.
 5. A surgical apparatus as recited in claim 4 , wherein thetextured surface on the periphery of the base is a gearing and thetextured surface on the retractor mounting assembly is a complementarygear tooth.
 6. A surgical retractor as recited in claim 1 , wherein thesurgical supporting structure has a protrusion formed thereon configuredto be received in one of a plurality of recesses defined in the base. 7.A surgical retractor as recited in claim 1 , which further comprises: anactuator associated with the surgical instrument supporting structureconfigured to translate rotational movement thereof to linear movementof the retractor blade.
 8. A surgical retractor as recited in claim 7 ,wherein the actuator has a pinion gear formed thereon configured toengage a rack formed on a portion of the retractor blade.
 9. A surgicalretractor as in claim 1 , wherein the retractor blade further includessuction, irrigation or blowing structure.
 10. A surgical retractor as inclaim 1 , wherein the retractor blade further includes a light.
 11. Asurgical retractor as in claim 1 , further comprising a second retractormounting assembly and a second retractor blade.
 12. A surgical as inclaim 1 , further comprising at least one suture mount positioned on thebase.
 13. A surgical retractor as in claim 1 , wherein the retractorblade includes a ratchet system for controlling slidable movement of theblade relative to the retractor mounting assembly.
 14. A surgicalretractor as in claim 13 , wherein at least a portion of the retractorsystem is formed on an outer peripheral surface of the retractor blade.15. A surgical retractor as in claim 13 , wherein at least a portion ofthe retractor system is formed on an inner peripheral surface of theretractor blade.
 16. A surgical retractor as in claim 1 , furthercomprising a transverse handle portion adjacent a proximal end of theretractor blade.
 17. A surgical retractor as in claim 1 , furthercomprising a strap adjacent a proximal end of the retractor blade tofacilitate retraction thereof relative to the retractor mountingassembly.
 18. A surgical retractor base comprising: a frame structuredefining an opening for effecting a surgical procedure therethrough; andat least one suture mount disposed adjacent a peripheral portion of theframe structure, the suture mount including a coil spring configured toretain a suture end portion therein.
 19. A surgical retractor base as inclaim 18 , further comprising at least one cavity defined in the framestructure for receiving at least a portion of the coil spring.
 20. Asurgical retractor base as in claim 19 , wherein the at least one cavitydefined in the frame structure is configured to retain the coil springin an orientation substantially transverse to a radian of the framestructure.
 21. A surgical retractor base as in claim 20 , furthercomprising a ramp defined in the frame structure adjacent the cavity.22. A surgical retractor blade assembly comprising: a retractor mountingassembly configured for lockable mounting to a base and defining acavity; a retractor blade slidably positionable at a plurality ofpredetermined locations in the cavity and including a distal portionangularly depending relative to a proximal portion; and a fluid assemblyintegrally formed with the retractor blade and including a distalportion extending independent of the distal portion of the retractorblade.
 23. A surgical retractor blade assembly as in claim 22 , whereinthe distal portion of the fluid assembly is independently positionablerelative to the retractor blade.
 24. A surgical retractor blade assemblyas in claim 22 , wherein the fluid assembly effects a negative pressureat the distal end thereof.
 25. A surgical retractor blade assembly as inclaim 22 , wherein the fluid assembly effects a positive pressure at thedistal end thereof.
 26. A surgical retractor blade assembly as in claim22 , wherein the fluid conveyed by the fluid assembly is selected fromthe group consisting of water, saline and air.
 27. A method of surgerycomprising the steps of: a) providing a monolithic base defining anopening therethrough and an outer peripheral portion having engagementstructure thereon; a retractor mounting assembly including a mountingbracket and mounting bracket engagement structure slidable along thebase and movable between a locked and unlocked position, in the lockedposition, the base engagement structure abutting the mounting bracketengagement structure to lock the reactor mounting assembly in apredetermined radial position, the retractor mounting assembly furtherdefining a cavity; and a retractor blade slidably positioned in thecavity and configured to retract tissue through the opening in the base;b) positioning the base on the patient such that the opening thereinoverlies the operative site; c) percutaneously accessing the operativesite through the opening; d) retracting obstructing tissue by engagingthe tissue with the retractor blade; and e) carrying out a surgicalprocedure through the opening in the base with said surgical instrument.28. A method as recited in claim 27 , wherein the retractor bladeincludes a ratchet assembly, and which further comprises the step of:fixing the position of the retractor blade with respect to the base withthe ratchet assembly.